Cut, Clip, Burn: A Combined Approach to Lung Cancer and Atrial Fibrillation.

Patients and Methods

Study Design
This retrospective case series was conducted at a single academic tertiary care institution. The study was approved by the University Hospitals Institutional Review Board (IRB# HRP-503UHDATA).

Patient Selection
All patients who underwent left-sided pulmonary resection with concomitant LAA ligation, as well as surgical ablation between July 1, 2022, and March 1, 2025, were identified through a review of the institutional surgical database and electronic medical records. Inclusion criteria were (1) age 18 to 80 years, (2) history of or risk factors for atrial fibrillation, and (3) left lung resection with simultaneous LAA ligation and surgical ablation. Patients were excluded if they did not meet the inclusion criteria or if relevant operative or postoperative data were unavailable. Four patients met inclusion criteria during the study period and were included. Surgical candidacy and procedural planning were determined through a multidisciplinary discussion between thoracic and cardiac surgical teams.

Data Collection
Patient data were abstracted from the electronic health record. The following variables were collected: age, sex, body mass index (BMI), smoking history, comorbidities, indication for surgery, anticoagulation status, operative details, and postoperative outcomes.

Outcomes
The primary outcomes were the feasibility and safety of concomitant LAA ligation during lobectomy, assessed by operative time, intraoperative complications, and early postoperative events. Secondary outcomes included the incidence of postoperative atrial fibrillation, thromboembolic complications, intensive care unit use, and 30-day outcomes.

Statistical Analysis
As a descriptive case series, no formal hypothesis testing was performed.

Results
Four patients (3 men) underwent concurrent left-sided lung resection, LAA ligation, and surgical ablation between May 2023 and February 2025. The median age was 72 years (interquartile range, 63-75 years). All patients had a history of paroxysmal atrial fibrillation and multiple cardiopulmonary comorbidities, including hypertension (3 of 4), coronary artery disease (2 of 4), and hyperlipidemia (3 of 4). Three patients had a history of non-small cell lung cancer (NSCLC) in the left upper or lower lobes, and 1 had interstitial lung disease requiring diagnostic biopsy. All patients were on anticoagulation at the time of surgery (Eliquis [Bristol-Myers Squibb] or Xarelto [Johnson & Johnson]), and all 4 were receiving antiarrhythmic therapy (metoprolol, with or without amiodarone) (Table 1).

Operative Details
All procedures were performed using a minimally invasive approach (video-assisted thoracoscopic or robotic). Surgical procedures included left upper or lower lobectomy (n = 2), wedge resection (n = 1), and segmentectomy (n = 1). All patients underwent posterior pericardial window creation and convergent endoscopic epicardial ablation without cardiopulmonary bypass. LAA ligation was performed using the AtriClip device in all cases (Table 2). There were no intraoperative complications.

Postoperative Outcomes
All 4 patients were admitted to the intensive care unit postoperatively for 1 day. Median hospital length of stay was 3 days (interquartile range, 2-5 days). Estimated blood loss ranged from 5 to 300 mL. Chest tube duration ranged from 2 to 4 days, with postoperative drainage volumes ranging from 120 to 1330 mL. All patients were discharged home (Table 2).

Thirty-Day and Long-Term Outcomes
There were no perioperative strokes, thromboembolic events, or deaths within 30 days. One patient required readmission for symptomatic bradycardia, which resolved with discontinuation of β-blockade. Another patient was readmitted for chest tube site bleeding, requiring no procedural intervention. All patients remained free from atrial fibrillation recurrence during the follow-up period (range, 3 months-2 years). Anticoagulation was discontinued for 2 patients at their 6-month follow-up appointments. One patient remained on dual therapy (aspirin and Xarelto), and 1 continued on Xarelto alone due to the need for continued follow-up. Therapy with class III antiarrythmics with amiodarone was discontinued in 2 patients at their 3-month follow-up appointment (Table 3).

Comment
In this case series, we demonstrate the feasibility and safety of combining left-sided pulmonary resection, convergent epicardial ablation, and LAA ligation in patients with atrial fibrillation undergoing thoracic surgery. Our results support the growing body of evidence suggesting that concomitant LAA exclusion and ablation during lung resection may be a valuable adjunctive strategy in carefully selected patients.1,4,5
Traditionally, LAA ligation has been performed in the context of cardiac surgery6; however, growing interest in minimally invasive approaches has expanded its use to patients undergoing thoracic procedures. Several prior reports have described the technical feasibility of LAA clipping during lung resections.1,4,5 These experiences, however, largely focused on LAA exclusion alone, without concomitant surgical ablation for rhythm control.
Our series builds on these findings by incorporating not only LAA ligation but also convergent endoscopic epicardial ablation, offering a combined strategy for both stroke prevention and rhythm management. Importantly, we observed no perioperative strokes, thromboembolic events, or deaths, and all patients remained free from atrial fibrillation recurrence during the follow-up period. These outcomes align with prior evidence demonstrating that surgical LAA occlusion significantly reduces the risk of thromboembolic events7 and that convergent epicardial ablation can improve rhythm outcomes in patients with persistent atrial fibrillation.8
Although our patients had slightly longer hospital stays (median, 3 days) and increased chest tube outputs compared with typical lobectomy patients who are on an enhanced recovery pathway,9 the absence of major complications and successful discharge home in all cases suggest that the additional procedural burden was acceptable. For patients likely to survive their primary pulmonary pathology, the potential stroke risk reduction and arrhythmia control may outweigh these modest increases in postoperative resource use.
Several technical considerations merit discussion. Performing epicardial ablation adds complexity to the operation but offers complementary benefit for rhythm control with the ablation and thromboembolic prevention with LAA ligation. Minimally invasive approaches (video-assisted thoracoscopic surgery or robotic) were used in all cases, consistent with literature demonstrating that the thoracoscopic and robotic LAA clipping and convergent procedure is technically feasible and associated with high success rates of complete occlusion.10

Limitations
This study has several important limitations. First, the small sample size of 4 patients inherently limits the generalizability of our findings. As a single-institution case series, the results may not be broadly applicable to other surgical practices, patient populations, or institutional protocols.
Second, the retrospective design introduces inherent biases, including potential for incomplete data capture and reliance on the accuracy of medical record documentation.
Third, there was no comparator group of patients undergoing lobectomy without LAA ligation and ablation, making it difficult to directly attribute postoperative outcomes to the LAA ligation and ablation intervention.
Finally, surgical technique, patient selection, and perioperative management decisions were at the discretion of individual surgeons, which may introduce variability that could influence outcomes. Larger, prospective, multicenter studies will be needed to validate the safety, feasibility, and long-term benefits of incorporating LAA ligation during pulmonary resections.

Conclusion
Our early experience suggests that combining left lung resection, epicardial ablation, and LAA ligation is safe and feasible in selected patients with atrial fibrillation. This combined strategy may offer an opportunity to reduce stroke risk and improve rhythm outcomes without significantly increasing perioperative morbidity. Future studies are warranted to assess long-term efficacy and to identify which patients derive the greatest benefit from this integrated surgical approach.